A BC D 1 - Florida Department of Highway Safety and Motor ...

STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES ? DIVISION OF MOTORIST SERVICES

SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OR LICENSE PLATE AGENT OFFICE locations/

APPLICATION FOR PERSONALIZED LICENSE PLATE

INSTRUCTIONS ARE INDICATED ON REVERSE SIDE

Date of Application

PLEASE CONTACT YOUR LOCAL COUNTY TAX COLLECTOR'S OFFICE, LICENSE PLATE AGENT OR REFER TO THE REVERSE SIDE OF THIS FORM FOR FEE INFORMATION.

OWNER / APPLICANT IDENTIFICATION

Owner's / Lessee's Name:

Sex:

Date of Birth:

Street Address:

City:

State:

Zip:

Owner's / Lessee's D/L Number:

Owner's / Lessee's E-mail Address:

FEID#:

Co-Owner's / Co-Lessee's Name:

Sex:

Date of Birth:

Street Address:

City:

State:

Zip:

Co-Owner's / Co-Lessee's D/L Number:

Current Decal Number: Title Number:

Co-Owner's / Co-Lessee's E-mail Address:

VEHICLE INFORMATION

Current License Plate Number:

Vehicle Type:

Vehicle Identification Number:

FEID#:

Vehicle Make:

Year:

Color:

Vehicle Weight:

CERTIFICATION

This is to certify that I am/we are the registered owner/lessee or co-owner/co-lessee of the motor vehicle referenced above. I/we authorize my/our name, address, and renewal date to be provided to the organization sponsoring the specialty license plate selected.

Under penalties of perjury, I/we declare that I/we have read the foregoing document and that the facts stated in it are true.

Signature(s):

LICENSE PLATE SELECTION (see reverse side for plate choices)

Enter the type of license plate requested: (see reverse

side of this form for types of plates and fees)

Specify the intended meaning/explanation for your personalized license plate configuration choice (nickname, initials, etc.):

Please Note:

? Use no more than the number of characters authorized for the type of license plate you have requested (including a space or hyphen, see reverse side).

? For license plates with center graphic, allow two spaces for the logo or characters will cover the graphic design.

Centered Graphic

(7 characters, may also have an additional space or hyphen. A regular motorcycle may have a Florida graphic.)

Left Graphic

(5 characters)

Specialty Motorcycle

(6 characters)

A B C 1 LOGO

D

1ST CHOICE

2ND CHOICE

3RD CHOICE

4TH CHOICE

INSTRUCTIONS

1. Carefully read all information on the front and back of this application before completing the application.

2. Complete the application form and submit it to your local county tax collector's office or license plate agent with the following items:

a. PROOF OF FLORIDA INSURANCE: Proof of personal injury protection (PIP) and property damage liability insurance (PDL) must be submitted in the form of a card, policy, binder, certificate of insurance or affidavit.

b. A copy of your current registration certificate or renewal notice. c. Remittance fees (payable to your county tax collector/license plate agent).

3. Please allow six to eight weeks for the manufacture and delivery of the license plate. The license plate will be delivered to your county tax collector's office or license plate agent.

HSMV 83043 (Rev. 08/21) S



IMPORTANT INFORM ATION ABOUT YOUR CHOICE

You may check personalized plate availability at the department's websitelocated at Your local county tax collector's office or license plate agent may assist you in determining if a specific type of license plate is available, as well as the choice for personalization and the total cost of the license plate you desire, including trucks (with a net weight of more than 5,000 pounds), "for-hire" vehicles and trailers.

? Yourchoice may include letters,numbers, aspaceor ahyphenascharacters.Licenseplatesthathave 7characters mayhave an additionalspace orhyphen. However,license plates thathave 5 characters, may NOThave an additional space orhyphen.

? Requests with obscene or objectionable words will be rejected. If a personalized license plate has been issued and later determined to be obscene or objectionable, the department will recall the license plate.

TYPE OF LICENSE PLATES

Personalized license plates for motorcycles are only available as a "Florida Graphic" or "Motorcycle Specialty" license plate.

TYPES OF LICENSE PLATES (See for more information)

AIR FORCE ** ARMY ** COAST GUARD ** INDIAN RIVER LAGOON **

MARINE CORPS ** NAVY ** OLYMPIC SPIRIT **

SALUTES VETERANS ** SHARE THE ROAD ** TAMPA BAY ESTUARY **

MAXIMUM CHARACTER FEES

5

$ 7 1 .4 0

CHOOSE LIFE ** EVERGLADES RIVER OF GRASS ** POLICE ATHLETIC LEAGUE ** PROTECT WILD DOLPHINS **

FISH FLORIDA**

SUPPORT EDUCATION ** SALUTES FIREFIGHTERS ** SUPPORT LAW ENFORCEMENT **

5

$ 7 6 .4 0

5

$ 7 8 .4 0

A STATE OF VISION ** AGRICULTURE EDUCATION ** ANIMAL FRIEND ** BIG BROTHERS BIG SISTERS ** BLUE ANGELS** CHALLENGER/COLUMBIA ** CONSERVE WILDLIFE ** DISCOVER FLORIDA HORSES** DISCOVER FLORIDA OCEANS ** END BREAST CANCER ** ENDLESS SUMMER** FALLEN LAW ENFORCEMENT OFFICERS** FLORIDA SHERRIFFS ASSOCIATION ** FLORIDASHERIFF'S YOUTH RANCHES**

FRATERNALORDER OF POLICE** FREEMASONRY ** GO FISHING ** HORSE COUNTRY ** HOSPICE EVERYDAY IS A GIFT ** IN GOD WE TRUST ** KEEP KIDS DRUG FREE ** KIDS DESERVE JUSTICE ** LAUREN'S KIDS ** NASCAR ** PLAY TENNIS ** PROTECT FLORIDA WHALES ** PROTECT OUR OCEANS**

PROTECT OUR REEFS ** (***) SAVE OUR SEAS ** SAVE WILD FLORIDA** STOP CHILD ABUSE ** SUPPORT AUTISM PROGRAMS ** SUPPORT HOMEOWNERSHIP FOR ALL** SUPPORT OUR TROOPS ** TREES ARE COOL ** VISIT OUR LIGHTS ** WALT DISNEY WORLD** WILDLIFE FOUNDATION OF FLORIDA**

MOTORCYCLE SPECIALTY ** FLORIDA GRAPHIC *

FLORIDA STATE MOTTO *

SPECIAL OLYMPICS FLORIDA *

AGRICULTURE * INVEST IN CHILDREN *

(***)AQUACULTURE * CONSERVE FLORIDA'S FISHERIES* FAMILY FIRST * FAMILY VALUES * HELPING SEA TURTLES SURVIVE *

STATE WILDFLOW ER *

SCOUTING TEACHES VALUES * STATE OF THE ARTS *

GOLF CAPITAL OF THE WORLD * IMAGINE* LIVE THE DREAM* PROTECT THE PANTHER *

PROTECT FLORIDA SPRINGS* SAVE THE MANATEE* STOP HEART DISEASE* UNITED WE STAND*

COLLEGIATE: BARRY UNIVERSITY ** BETHUNE-COOKMAN UNIVERSITY ** EDWARD WATERS COLLEGE ** EMBRY-RIDDLE AERONAUTICAL UNIVERSITY ** FLAGLER COLLEGE ** FLORIDA A & M UNIVERSITY ** FLORIDA ATLANTIC UNIVERSITY ** FLORIDA COLLEGE ** FLORIDA GULF COAST UNIVERSITY ** FLORIDA INSTITUTE OF TECHNOLOGY ** FLORIDA INTERNATIONAL UNIVERSITY ** FLORIDA MEMORIAL UNIVERSITY **

FLORIDA SOUTHERN COLLEGE ** FLORIDA STATE UNIVERSITY ** JACKSONVILLE UNIVERSITY ** KEISER UNIVERSITY ** LYNN UNIVERSITY ** NEW COLLEGE OF FLORIDA ** NOVA SOUTHEASTERN UNIVERSITY ** PALM BEACH ATLANTIC UNIVERSITY ** RINGLING SCHOOL OF ART AND DESIGN * * ROLLINS COLLEGE ** SAINT LEO UNIVERSITY ** SAINT THOMAS UNIVERSITY **

SOUTHEASTERN UNIVERSITY ** STETSON UNIVERSITY ** UNIVERSITY OF CENTRAL FLORIDA ** UNIVERSITY OF FLORIDA ** UNIVERSITY OF MIAMI ** UNIVERSITY OF NORTH FLORIDA ** UNIVERSITY OF SOUTH FLORIDA ** UNIVERSITY OF TAMPA ** UNIVERSITY OF WEST FLORIDA ** WARNER SOUTHERN COLLEGE **

ECKERD COLLEGE*

FLORIDA HOSPITAL COLLEGE OF HEALTH SCIENCES*

5

$ 8 1 .4 0

6

$ 7 3 .4 0

7

$ 5 1 .4 0

7

$ 7 1 .4 0

7

$ 7 6 .4 0

7

$81.40

7

$ 7 9 .4 0

5

$ 8 1 .4 0

7

$ 8 1 .4 0

FLORIDA PROFESSIONAL SPORTS TEAM: FLORIDA MARLINS **

MIAMI HEAT ** ORLANDO MAGIC **

TAMPA BAY LIGHTNING ** TAMPA BAY RAYS**

5

JACKSONVILLE JAGUARS **

TAMPA BAY BUCCANEERS **

MIAMI DOLPHINS **

FLORIDA PANTHERS *

6

Amount Includes All Fees (SEE "FEE EXCEPTIONS" BELOW ).

*Graphic design is centered on the plate

**Graphic design is on the far left/right side of the plate.

***If applying for more than 10 license plates for the same owner the fee is $67.55 per license plate.

FEE EXCEPTIONS: An additional branch fee of $.50 may be required by some county agencies.

An additional license plate mail fee of $4.70 is required if a license plate is mailed to the applicant.

The annual or biennial registration fee is due in addition to these fees shown.

Visitthe following website for current mailing addresses:

HSMV 83043 (Rev. 08/21) S



$ 8 1 .4 0 $ 8 1 .4 0

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